History of tuberculosis
It may surprise you to learn that tuberculosis was called "the white plague" in the 19th century. How and why did it become a threat just as medicine finally began to succeed in the 19th century?
It may surprise you to learn that tuberculosis was called "the white plague" in the 19th century. We don't associate tuberculosis with epidemics and mass graves. Yet, in Western Europe, more people died from this disease than from any other. However, the tuberculosis bacterium did not originate in the 19th century. Palaeontologists have shown that it was already present in prehistoric times.
How and why did it become a threat just as medicine finally began to succeed in the 19th century?
Today, it does not scare us so much; why?
The origin of tuberculosis
While our ancestors often stumbled in the dark about the origins of diseases and were led astray by delusional notions, we know. The bacterium Mycobacterium tuberculosis is the causative agent of the disease called "consumption." As a mycobacterium, it belongs to the same group as the bacillus that causes leprosy.
Robert Koch discovered it on March 24, 1882, and won the Nobel Prize. However, the path to recognition of the bacterial origin of tuberculosis was not straightforward. Society clung to the idea that tuberculosis was not contagious, and for various reasons, it was hard to accept the truth.
Moreover, many questions remained unanswered. Why did some patients develop no symptoms when exposed to the bacterium? Why did someone die immediately, and another lived for many years with the disease in a chronic phase? Most importantly, why did the disease appear to pass from parents to children?
Microscopic killers were beyond most people´s imagination in the 19th century. And we're not just talking about the uneducated population. The scientific community, too, long resisted the theory of the bacillus as the cause of the disease.
The contagiousness of tuberculosis and the course of the disease
Infection with Mycobacterium tuberculosis does not mean that a person will develop symptoms at all during his or her lifetime. In most cases, the immune system 'preserves' the bacterium when it enters the body, enveloping it so it can no longer multiply. Why some people can do this and others cannot has remained a puzzle for immunologists until these days. Risk factors are known, but no one is sure.
Still, tuberculosis remains a threat in our world. Even today, if tuberculosis enters the active phase, the mortality rate without appropriate antibiotic treatment is about 50%. Moreover, highly resistant strains are circulating in some countries, making antibiotic therapy difficult. At the time of Koch's discovery, however, antibiotics were unknown. What puzzled the experts then was that co-morbidities manifested differently in different individuals. Some people came down quickly; others spent years with a debilitating cough and pale skin before they died.
Moreover, contemporary medicine could not tell who was cured. If the symptoms subsided, the patient was declared healthy. But he could still spread the disease.
The theory of heredity in the history of tuberculosis
The disease ran in families. But its chronic nature confused people. If the disease were transmitted within a family through contagion, the whole family would have to get sick at once. As people knew it from the plague epidemics. However, some individuals with tuberculosis did not suffer the first manifestations of the disease until long after the death of their parents, killed by the very same bacillus. That implied that the disease ran in the blood because infection, however people understood its mechanisms, would have shown some symptoms earlier.
A romantic history of tuberculosis
We are in the Romantic period. And Romanticism liked stories of disgraced suffering geniuses. Romantics were drawn to suffering, death and illness. So, the history of tuberculosis has passed into culture. The age dreamed up the pale, beautiful girl suffering silently on a balcony with a panorama of mountains or sea. Elegantly coughing into a lace handkerchief. She will soon leave her lover for eternity. Or a talented artist who knows he doesn't have much time left. He goes to the country because a change of scenery will prolong his life. And there, he creates his masterpieces, knowing that death is imminent.
Of the most famous Romantic souls, the German poet Novalis, the English poet John Keats, the great Romantic writer Percy B. Shelley, Emily and Anne Brontë, and Frederic Chopin died with a cough on their lips. Tuberculosis killed many other romantic authors we will never learn about because they were not so gifted.
The epidemic reality looked very different but left the romantic writers unaffected. These associated their ideas with sensitive souls, a handkerchief with bloodstains, and a desire to create a masterpiece before our last journey. Tuberculosis had become fashionable in certain circles. Pale make-up, unnatural thinness, subtle coughing, sadness and forgetfulness, lack of appetite, and being in the sea or mountain air are what ladies in the mid-19th century dreamed of.
However, the actual history of tuberculosis was far from this ideal. In most Western countries, the number of deaths caused by the tuberculosis bacteria ranged between 300 and 500 per 100,000 inhabitants. And there was nothing romantic about their end.
The history of tuberculosis is moving in the right direction.
However, the numbers began to fall by the end of the 19th century. Each country approached the highest number of deaths at slightly different times, but the curve was always reversed. This trend was not at all related to treatment. The cause of the disease was not discovered until 1882, and antibiotics, as the only reliable treatment, did not come into practice until after the Second World War.
People tried to fight the disease. They developed a semi-effective cure and moved patients to sanatoriums. By the 1920s, a vaccine was known, but society didn't find its way to it until the late 1950s. Historians now believe that nothing people did directly against the spread of the disease did much to eradicate it. Ultimately, the most significant contribution was the change in society's lifestyle. At the beginning of the 19th century, social change also caused a sudden increase in cases.
The coming of the White Plague
The Industrial Revolution caused the white plague epidemic in Western Europe. At first, people moved frantically to the cities, which were unprepared for the influx of the masses. Houses were built close together, often without windows to occupy space, and several families lived together in one unit.
The gradual introduction of compulsory schooling brought about mixing children from different households in different and, again, cramped, unventilated spaces. Apart from the fact that there was often no way to ventilate because of the lack of windows, there was also no desire to open them. The industrialisation of cities brought enormous air pollution. The air in industrial cities was downright poisonous. People hid from it indoors and would not let it into their homes at any cost.
The White Plague leaves… or does it?
In addition, the second half of the 19th century saw increased grain imports from overseas. After initial protests, European farmers had to adapt and started growing other crops to feed their buyers. As a result, fruit and vegetables became more common in people's diets. In addition, animal products reached more people thanks to better ways of preserving and transporting food. In short, the poor were still dying of malnutrition, but there were fewer and fewer poor.
What did these changes mean for the history of tuberculosis? People were healthier and more resilient. After the first waves of the Industrial Revolution subsided, the migration into cities became less and less frantic. People lived in larger houses, and industrialisation brought its fruits in making people wealthier and improving the population´s lifestyle. They didn't live in crowded spaces anymore, breathed better air, had more ventilation, and had fewer children.
The history of disease is full of mysteries and theories. Perhaps that's because immunology and infectious diseases also pose many unanswered questions for scientists today, as we learned to accept with humility in 2020.
Tuberculosis today
Tuberculosis has not yet had its final word. It is still quite common in poorer and overpopulated countries and kills reliably. Moreover, antibiotics are used quite irresponsibly in these countries, which, together with the inherent properties of Mycobacterium tuberculosis, leads it to develop resistance to them. According to WHO data, up to 20% of cases are now caused by antibiotic-resistant strains. However, this is not just a tuberculosis case. Nor is it a case for the historian.
How does knowledge of history help us struggle with diseases? We can spread awareness of what we still don't know and understand. We can tell stories of the people of the past who were helpless against disease and perhaps help restore some of that humility toward germs. Now, we may feel there's no need. Since 2020, we've been full to the brim with humility. But humanity has a short memory. That's why we need historians.